A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following is the BEST indicator of true labor that the nurse should recognize?
Premature rupture of the membranes.
Light irregular pattern of contractions.
3 station of the presenting part.
Progressive cervical dilation.
The Correct Answer is D
Choice A rationale
Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.
Choice B rationale
Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.
Choice C rationale
3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.
Choice D rationale
Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7"]
Explanation
Step 1 is 2800 grams × 2.5 mg/kg. 2800 grams × 2.5 mg/kg = 7000 mg/kg.
Step 2 is 7000 mg ÷ (1000 mg/kg). 7000 mg ÷ (1000 mg/kg) = 7 mg.
Final calculated answer: 7 mg.
Correct Answer is C
Explanation
Choice A rationale
Hydration is important for maintaining maternal fluid balance and energy during labor, but it does not specifically address the severe backache experienced by the client.
Choice B rationale
Amniotomy can stimulate labor progression but is not specifically indicated for relieving back pain associated with labor.
Choice C rationale
Counterpressure to the sacrum can help alleviate back pain during labor, especially if the baby is in an occiput posterior position, which causes severe backache. Applying pressure to the sacrum can provide relief and comfort to the laboring client.
Choice D rationale
Urinary catheterization may be necessary if the client is unable to void, but it does not address the primary issue of severe back pain during labor.
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